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psnet.ahrq.gov/node/836892/psn-pdf
April 07, 2022 - from all levels of staff to a culture of emergency critical care provision, knowledge
acquisition, skill
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psnet.ahrq.gov/node/73128/psn-pdf
July 01, 2022 - Hospital at Home? Care Reduces Costs, Readmissions,
and Complications and Enhances Satisfaction for Elderly
Patients.
April 7, 2021
https://psnet.ahrq.gov/innovation/hospital-homesm-care-reduces-costs-readmissions-and-complications-
and-enhances
Summary
The Hospital at Homesm program provides hospital-level care…
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psnet.ahrq.gov/node/60977/psn-pdf
January 08, 2020 - Multiple Levels Involved in Prescribing the Wrong
Medication
September 30, 2020
Chin K, Chau V, Spero H, et al. Multiple Levels Involved in Prescribing the Wrong Medication. PSNet
[internet]. 2020.
https://psnet.ahrq.gov/web-mm/multiple-levels-involved-prescribing-wrong-medication
The Case
A 65-year-old woman co…
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psnet.ahrq.gov/node/73153/psn-pdf
April 28, 2021 - to understand how to encourage safety-enhancing
collaborative behaviors among nurses with different skill
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psnet.ahrq.gov/web-mm/difficult-encounters-cmo-and-cno-respond
March 01, 2018 - SPOTLIGHT CASE
Difficult Encounters: A CMO and CNO Respond
Citation Text:
Ring EJ, Hirsch JE. Difficult Encounters: A CMO and CNO Respond. PSNet [internet]. Rockville (MD): Agency for Healthcare Research and Quality, US Department of Health and Human Services. 2009.
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…
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psnet.ahrq.gov/perspective/conversation-withbarbara-blakeney-ms-rn
August 01, 2005 - We believe that there is a way to take the environment and the skill set of the nurses into account. … technology in the unit; the admissions, discharges, and transfers into and out of the unit; and the nurses' skill … To the extent that we don't have a full appreciation of each other's skill sets and knowledge base, we
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psnet.ahrq.gov/sites/default/files/2020-08/too_many_cooks_spotlight_pdf.pdf
January 01, 2020 - Cardiac anesthesiologists are comfortable with placing a TEE probe and
interpreting images, but this skill
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psnet.ahrq.gov/primer/patient-safety-101
January 16, 2025 - treated errors as failings on the part of individual providers, reflecting inadequate knowledge or skill
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psnet.ahrq.gov/issue/learning-adverse-events-and-near-misses
January 15, 2020 - Commentary
Learning from adverse events and near misses.
Citation Text:
Greenberg CC. Learning from adverse events and near misses. J Gastrointest Surg. 2009;13(1):3-5. doi:10.1007/s11605-008-0693-6.
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DOI Google Scholar PubMed BibTeX EndNote X3 XML En…
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psnet.ahrq.gov/issue/clinical-cognition-and-biomedical-informatics-issues-patient-safety
September 04, 2024 - Commentary
Clinical cognition and biomedical informatics: issues of patient safety.
Citation Text:
Patel VL, Currie L. Clinical cognition and biomedical informatics: Issues of patient safety. Int J Med Inform. 2005;74(11-12). doi:10.1016/j.ijmedinf.2005.07.009.
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psnet.ahrq.gov/issue/first-do-no-harm-lost-concept-medical-education
December 01, 2004 - Commentary
Is "first do no harm" a lost concept in medical education?
Citation Text:
O'Leary D. Is "first do no harm" a lost concept in medical education. MedGenMed. 2006;8(3):77.
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Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagg…
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psnet.ahrq.gov/issue/cutting-out-human-error
February 25, 2009 - Commentary
Cutting out human error.
Citation Text:
Feinmann J. Cutting out human error. BMJ. 2008;337:a2370. doi:10.1136/bmj.a2370.
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Format:
DOI Google Scholar PubMed BibTeX EndNote X3 XML EndNote 7 XML Endnote tagged PubMedId RIS
Download Citation …
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psnet.ahrq.gov/issue/error-reduction-through-team-leadership-applying-aviations-crm-model-or
September 25, 2013 - Commentary
Error reduction through team leadership: applying aviation's CRM model in the OR.
Citation Text:
Healy GB, Barker J, Madonna G. Error reduction through team leadership: applying aviation's CRM model in the OR. Bull Am Coll Surg. 2006;91(2):10-5.
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…
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psnet.ahrq.gov/issue/medically-induced-trauma-support-services-mitss
December 07, 2016 - Newspaper/Magazine Article
Medically Induced Trauma Support Services (MITSS).
Citation Text:
Medically Induced Trauma Support Services (MITSS). Tobin WN. Patient Safety Quality Healthcare. May/June 2013.
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psnet.ahrq.gov/web-mm/physical-diagnosis-lost-art
January 17, 2018 - Although few studies examine physical diagnosis skills over successive generations of physicians, skill … skills in North America will ever come back to their apogee, when this art form was practiced with great skill … Without leadership in this area from regulatory organizations and specialty societies, this skill set
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psnet.ahrq.gov/node/49491/psn-pdf
September 01, 2005 - Simulation offers a potential solution for resuscitation skill acquisition and retention. … shows objective improvements in ACLS proficiency, subjective
ratings of both confidence in one’s own skill … The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177-181.
5.
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psnet.ahrq.gov/web-mm/time-death
January 03, 2017 - Simulation offers a potential solution for resuscitation skill acquisition and retention. … shows objective improvements in ACLS proficiency, subjective ratings of both confidence in one’s own skill … The five-stage model of adult skill acquisition. Bull Sci Technol Soc. 2004;24:177-181. 5.
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psnet.ahrq.gov/issue/uncovering-risks-anticancer-therapy-through-incident-report-analysis-using-newly-developed
January 29, 2018 - Almost Fatal Medication Error
June 1, 2018
Clinical scenarios: enhancing the skill
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psnet.ahrq.gov/issue/safety-culture-and-complications-after-bariatric-surgery
August 02, 2015 - August 2, 2015
Surgical skill and complication rates after bariatric surgery.
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psnet.ahrq.gov/issue/sensitivity-routine-system-reporting-patient-safety-incidents-nhs-hospital-retrospective
March 28, 2012 - February 15, 2010
Surgical skill is predicted by the ability to detect errors.